A Lady with Worms Crawling Out of Her Skin – An Unusual Case
One day the team was sitting in the breakroom after lunch and, to their surprise, Dr. Darko walked in and sat down. It’s always (well, almost always) good to see him and to sit and chat for a bit. After 30 years of treating patients he has a lot of stories he can tell (though always keeping patient confidentiality). Jack recalled a mention long ago of one of his odd, old cases and asked if it was true about the lady with worms coming out of her skin. Dr. Darko smiled and nodded yes, it was indeed true. He could tell he was being baited into a story.
The Case of A Lady with Worms Crawling Out of Her Skin
She was a blond from Las Vegas, thus, probably not unusual. She had brought herself to the big renowned medical center on the coast for help. After seeing several doctors in Las Vegas and not getting satisfactory answers, she saw a few in Reno. Having the feeling that she was being dismissed as some kind of nut, but really distressed about her condition, she came to the large regional referral clinic where our CEO was a Division Head in the Department of Medicine. The referral desk didn’t know quite what to do with her, so they scheduled her into the General Internal Medicine Clinic.
The Start of Any Medical Visit – The Chief Complaint
And so it was that the lady presented herself at the check-in desk for Internal Medicine. The referral form in her hand listed the Chief Complaint as, “Worms crawling out of my skin.” It was an unusual chief complaint that startled the front desk admin. She asked the lady to have a seat and quickly scooted back to the medical area to ask if this patient was in the right place and, if so, with which doctor she should schedule her. The general opinion of the medical professionals there was to slot the woman into the next open exam room, just like any other patient. About 15 minutes later an exam room opened up for a next person, was cleaned and readied. The woman was escorted from the waiting room to the exam room.
Enter the Good Doctors
Exam rooms in medicine clinics are most always small, sparce, and maybe chilly. This one was typical. She sat there for about 15 minutes waiting. After not that long a wait, one of the internists in the clinic came in to see her. With the good doctor in a white coat was a resident doctor, and intern, and a medical student. A good crew for a learning expedition. She described to the four of them that, every now and then, maybe one every few weeks, a worm would crawl out of her skin. It really upset her to think that she had worms inside her and that one would occasionally crawl out. No, she couldn’t show them any of the places where one came out because a few days after one comes out the little hole has healed closed. And, she doesn’t have any of the dead worms to show them. When one comes out she quickly brushes really hard to get it off her skin but then can’t find the worm anywhere.
The Dilemma of the Negative Medical Exam
The internist gathered her medical history in textbook fashion as he was teaching the other three how to do it. It all seemed pretty normal for a woman who grew up in rural Nevada and moved to Las Vegas for work after high school. She had been fairly healthy through her life, trying to live a healthy lifestyle as a young blond in Las Vegas. Height, weight, and BMI were average, visual acuity was normal. She smoked a lot and drank a little, didn’t exercise much, and ate a surprisingly healthy diet, given everything else. Her blood pressure was normal and her vaccinations were up to date. The exam of the heart and lungs were normal, as was her abdominal exam. She had no history of sexually transmitted diseases. No history of psychiatric or neurological conditions. At the end of the visit, after the intern and medical student went on their way, the internist and resident did a breast exam, Pap and pelvic. Laboratory tests were ordered for lipids, glucose, blood chemistries, and urinalysis.
Where to Go Next – The Referral Chain
After two hours, with the results the four of them had in hand, the internist, resident, intern, and medical student discussed where to send her. It was unlikely that anything would come back from the labs still pending to explain the chief complaint of worms. General internal medicine was hitting a brick wall with no ideas at this point. Probably they should refer her next to Infectious Diseases, where they have a parasitologist who might know about worms that infect people. Maybe Dermatology? No, the internists found nothing for the docs in Derm to see. But, yeah, there’s that doc in Infectious Diseases who knows a lot about tropical infections and infestations, like parasites. The team writes down her medical history, the resident records her physical exam, the intern fills out the needed paperwork, and they send to off to the scheduling desk to make an appointment with Parasitology.
Wriggling Into and Out Of Parasitology
The main guy, the parasitologist who knows this stuff, is on vacation, so they schedule her for the next week. She has to go back to Las Vegas then come back to the clinic. The internist does instruct her that, if a worm comes out before her appointment in parasitology she should try to collect it in a bottle and bring it to show the Infectious Disease staff. She returns the next week, no worm in a bottle, because no new ones have wiggled out. The parasitologist hears her story and does his physical exam. He did get one valuable piece of information that had not come out before. The worms only seem to come out of her forearms and hands. He examines her forearms and hands with a magnifying headlamp. The skin is roughened more than it should be for her age but no sign of worms.
There Really Are Worms That Crawl Out of the Skin
There really are worms that can crawl out of a person’s skin. One is the guinea worm that comes from drinking contaminated water. It goes out of the person’s stomach, moves about in their body for about a year, then comes out through the skin. But, a guinea worm didn’t fit with growing up and living in Nevada. There’s the chigoe flea (or jigger flea or sand flea), a parasite that grabs onto a person’s skin. But chigoe fleas are on the skin, not popping out of the skin. Filarial worms? No. Screwworm? No. Common louse? No, that doesn’t fit either. Nothing fit. There was no worm infestation that fit this woman’s history, physical exam, and description, even with a wide, wide stretch of the imagination. Then to which Division to refer?
When Something Is Wrong and No One Knows Why – The Psychiatry Division
The internist and parasitologist talked about the case over lunch. A surgeon and a radiologist were sitting at the same table in the doctor’s lunch room and joined the discussion. This foursome snagged a pathologist on his way out, and he sat down, too. What to do, what to do? There is this syndrome called “delusional parasitosis”. Maybe she has that. Her story doesn’t make all that much sense. Maybe she’s just crazy. No one has actually seen one of the worms, or any holes where they came out. Dr. Darko is the Division Head of Psychiatry, send her to him. He’s good. Maybe he can solve this mystery. After all, she must have delusional something!
What in the World is Delusional Parasitosis?
Obviously delusional parasitosis is a “mental” disorder. That is, a physical brain disorder that everyone calls a “mental” disorder. (See our page on Your Mind & Your Brain.) A delusion is a fixed false belief. People who have this specific delusion falsely believe that they are infested with some living creature. Like, for example, a parasitic worm. Of course, like most “mental” disorders, no one knows what causes it. If there’s no other sign or symptom of psychosis and the belief’s gone on for at least a month, and there’s no other explanation, then it’s delusional parasitosis. If it’s so, a medicine for psychosis will fix it right up. Oh, and while it is rare, it is seen twice as often in women as in men, so, there you have it.
The Looney Bin is Not A Bin and Not Headed by a Looney
You’d have to know Dr. Darko to know what to expect next. While he’s not an internal medicine doc, he is a Fellow of the American College of Physicians, and has been for almost 40 years. Most of his 30 year clinical career was as a consulting psychiatrist in a general medical hospital. He’s done his time in the psychiatrist’s chair, of course, but has also stood nose-to-nose with many an internist and surgeon telling them just which patient does have a problem and which one is not crazy. And so it was to that very chair in the office of the Head of the Psychiatry Division that the blond lady from Las Vegas later found herself.
You Mean There’s Really A Medical History Here?
Of course, the referral paperwork needed to ricochet about the innards of the clinic first. The woman from Las Vegas had to again go home and get on the schedule to be seen in Psychiatry. And she was not happy about it. She had damn worms crawling out of her skin and people thought she was crazy. This all took place back in the days of paper medical records. There were stacks of records from the doctors in Las Vegas and Reno, and the records from the recent visits to the clinic. Dr. Darko stayed late the evening before the day of her appointment, reviewing it all.
Oh Joy. The Big Day Meeting the Psychiatrist
While she was pleasant enough and seemed to be trying to be open-minded, she felt seeing a psychiatrist was a put-down and an insult. And she said as much. When you’re a lady with worms crawling out of your skin, what help is a shrink? Dr. Darko was used to this attitude as a first hello. He repeated gathering her medical history, though of course with a psychiatric bent, and did the full-blown mental status exam part of the physical exam. Since the worms always came out of her forearms and hands, he spent a lot of time talking about her forearms and hands. Unfortunately, they ran out of time at that first visit and she had to schedule to come back. For some reason she didn’t seem that upset about this inconvenience.
Aha! Will Wonders Never Cease?
At that second visit she said that she had gotten interested in Dr. Darko’s questions about her arms and hands. She’d been thinking about that and his questions about her jobs and occupations. As it turned out, there was a time when the lady with worms crawling out of her skin worked for an antique auto restoration shop in Las Vegas. Not restoring cars herself but cleaning parts. The mechanics would tear a car apart for restoration, and separate out the parts that were too rusted or corroded to just brush off and put back. The shop employed several parts-cleaning people who would take the parts and clean them in these boxes. The shop also cleaned antique metal art objects and motorcycle restoration parts. Occasionally the odd piece of boat or bicycle hardware would show up.
An Old Shop with Old Equipment
She said the boxes were these boxes that were clear on the top and front, and the front lifted up to put things in the boxes. The front had two holes with thick black rubber gloves in them. A part-cleaner staff member would put the part in, close the front, put their hands and forearms in the gloves, and step on a peddle to shoot the cleaning sand on the part. The box protected the operator from the sand and the gloves protected the forearms and hands. She quit after a few months, though, because some of the boxes were old and the gloves had cracks and holes in them. If she couldn’t get to one of the newer boxes and had to use one of the older ones her arms and hands would hurt at night. She didn’t like the job, so the lady with worms coming out of her skin quit.
The Fine Art of Glass Bead Blasting
There are several types of blasting in shops. Glass beads are one of the media used for blasting, including finishing, cleaning, deburring and peening. Finishing is texturing a part after it’s been coated to give it a burnish. Cleaning is blasting off caked-on grime and dirt. Deburring is smoothing bits of metal left from welding, and peening makes cracks in a surface in a way that can help performance. The lady from Las Vegas didn’t know which of these she was actually doing, but she thought probably she cleaning, mainly because that’s what they called it. She didn’t put the sand in the holder, one of the mechanics put it in. She didn’t know if it was glass bead blasting media, they just called it sand. But she does recall them saying they don’t use real sand because it could be dangerous. Dr. Darko asked her to get details from the shop before their next visit.
The Worm Mystery is Solved
The people at the shop wouldn’t talk with her because they thought she was trouble and might sue them. In trying to find something out, though, there was a new young guy working in the shop. She offered to buy him a drink if he’d talk to her about how the blasting really worked. He said they do glass bead blasting with a fairly large size glass bead media. He added that the shop people are wary because some of their older blasting cabinets were leaky and had old, cracked gloves. People were getting hurt from the old boxes so they had to get rid of all of them. They bought all new cabinets. They didn’t want old employees coming around and causing trouble, like maybe, a lady with worms coming out of her skin.
The Worms Go In, The Worms Go Out
The truth began to dawn on the lady with worms coming out of her skin. And happily, before her next visit with Dr. Darko, a worm came out. Realizing now that it might not be a worm after all but just a glass bead, she looked at it carefully rather than fearfully brushing it away. She picked it up and put it in a bottle to show Dr. Darko. It was a clear little glass bead. She thought it odd that she was happy to go back and see the psychiatrist again. Best not make a habit of THAT! That was her last visit with Dr. Darko or anyone at the big clinic on the coast. He did not know if she sued the restoration shop, but probably not. None of the clinic docs were ever called to give information. Likely, having evaluated her personality, she just forgot about the whole thing and got on with her life, embarrassed that she ever thought she had worms coming out of her skin.